Australian civilian hospital nurses’ lived experience of an out-of-hospital environment following a disaster

Australian Civilian Hospital Nurses’ Lived Experience of the Out-
of-hospital Environment Following a Disaster
Jamie Clemith Charles Ranse, RN FACN FCENA
BNurs (Canberra), GCertClinEd (Charles Sturt), GCertClinEpi (Newcastle), MCritCarNurs (Canberra).
A thesis submitted for the fulfilment of the
requirements of the degree of
Doctor of Philosophy
College of Nursing and Health Sciences
Flinders University
Adelaide, South Australia
31 August 2017

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For those nurses who have, and those nurses who will, unconditionally put aside their lives to
assist people affected by the adversity of disasters; particularly for civilian hospital nurses in
the out-of-hospital environment following a disaster.

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Abstract
Disasters disrupt the normal functioning of communities. From a health perspective, disasters
may place an increased demand on health services within affected communities. When a
disaster occurs, Australian nurses may respond as part of a government or non-government
disaster medical assistance team. There is an increasing international literature base of nurses’
personal experiences and descriptions of single disastrous events. However, Australian
civilian hospital nurses’ lived experience of the out-of-hospital environment following a
disaster has not yet been explored.
Phenomenology is concerned with the essence of things as they are appearing in the conscious
awareness of the first person. This phenomenological study uncovered what it may be like
being an Australian civilian hospital nurse in the out-of-hospital environment following a
disaster. Hermeneutics and phenomenology formed the theoretical framework for this study.
While there is no one way to do phenomenology and get back to the things themselves as they
are appearing in themselves, for this study, an epoché and reduction were the key methods of
phenomenology in guiding a way.
To get to the essence of the phenomenon being uncovered, narrative was obtained from eight
participants, using semi-structured interviews at two points in time. Participants were
Australian civilian hospital nurses who had worked in the out-of-hospital disaster
environment as part of a disaster medical assistance team. From the participant narratives,
descriptive moments formed a lived-experience description as an anecdote of what it may be
like being a nurse in an out-of-hospital environment following a disaster. The uncovered
moments in this study included ‘on the way to a disaster’, ‘prior to starting work’, ‘working a
shift in a disaster’, ‘end of a shift’ and ‘returning home’. Phenomenological reflections of the
existentials of spatiality, corporeality, communality and temporality overlaid the moments of

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the lived-experience description. Commentary on the phenomenological reflections provided
further depth to the insights of what it may be like being an Australian civilian hospital nurse
in the out-of-hospital environment following a disaster.
A nurse’s experience following a disaster, from a spatial perspective, was described in this
study as lived-space as shrinking then opening too-wide, and disaster health lived-space as
occupying, sharing and giving back. From a corporeal perspective, their experience was
described as a nurse’s lived-body, for nursing following a disaster, and a nurse’s lived-body,
for patients following a disaster. From a communal perspective, their experience was
described as with colleagues, being relationally close; with patients and their families, being
an insider; and being with self. From a temporal perspective, their experience was described
as kairos time speeding up and condensing and kairos time slowing down and stretching.
Chronos time emerged as a featured backdrop to the life-world of what it may be like being
an Australian civilian hospital nurse in the out-of-hospital environment following a disaster.
In particular, chronos time was described as intersecting between the uncovered moments and
the phenomenological existentials as a way to gain greater insights of a possible experience.
These insights, in turn, informed possibilities for future practice, future education and
professional development, and future research related to the experience of an Australian
civilian hospital nurse in the out-of-hospital disaster environment as part of a disaster medical
assistance team following a disaster.

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Statement of Authorship
I certify that this thesis does not incorporate without acknowledgement any material
previously submitted for a degree or diploma in any university; and that to the best of my
knowledge and belief it does not contain any material previously published or written by
another person except where due reference is made in the text.
Candidates’ signature:
Date: 31 August 2017

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Acknowledgements
This research was supported by the Annie M Sage Memorial Scholarship, a competitive
research scholarship from the Royal College of Nursing Australia [now Australian College of
Nursing].
I would like to acknowledge the ongoing support, guidance, expert advice and gentle
persuasiveness of my supervisors: Professor Paul Arbon, Associate Professor Lynette Cusack
and Professor Ramon Shaban. In particular, I would like to thank Paul for his ongoing
mentorship and professional guidance throughout my career.
It is pertinent to acknowledge the time, energy and willingness of the nurses who provided in-
depth narrative about their experience of being a nurse in an out-of-hospital environment
following a disaster. Your contribution to this work is of great significance and importance.
Thank you to my colleagues from Flinders University and the University of Canberra who
showed an interest in my work. Additionally, thank you to Professor Alison Hutton for the
informal conversations of encouragement; Dr Karen Hammad for the general discussions and
sharing of our PhD journeys; and Dr Daniel Nicholls, who guided me through my early
learnings of phenomenology.
Thank you, Bas Levering, Max van Manen, Cathy Adams and Michael van Manen for your
discussion, debate and guidance during the Phenomenology of Practice and the Tradition of
the Utrecht School at the 2013 Utrecht Summer School. These interactions have guided much
of this work. In particular, thanks to Max for his continued discussion and support since the
summer school, for which I am grateful.

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Finally, and most importantly, to my family: Kristen, my wife—this would not have been
possible without your love, care and insight into my journey. My children Charlotte, Sadie
and Lucas, who see me disappear into the study for many hours and to Adelaide for many
days. I hope this demonstrates that throughout life, persistence and hard work is rewarded.

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Contents
Abstract ..................................................................................................................................iii
Statement of Authorship..........................................................................................................v
Acknowledgements..................................................................................................................vi
Contents ................................................................................................................................viii
List of Tables...........................................................................................................................xii
List of Figures.........................................................................................................................xii
Abbreviations and Acronyms...............................................................................................xiii
Prelude ...................................................................................................................................1
Canberra Bushfire 2003..........................................................................................................1
Chapter 1: Introduction...........................................................................................................4
1.1 Australian Disaster Medical Assistance Arrangements ...................................................6
1.2 Australian Nurses in the Out-of-hospital Environment Following a Disaster .................9
1.3 Problem Statement .........................................................................................................10
1.4 Structure of this Thesis...................................................................................................12
Chapter 2: Literature Review ............................................................................................... 15
2.1 Introduction ....................................................................................................................15
2.2 Nurses’ Clinical Experience........................................................................................... 16
2.3 Nurses’ Disaster Medical Assistance Team Affiliation .................................................18
2.4 Nursing Practice .............................................................................................................19
2.5 Injury and Illness Assessment and Management ........................................................... 20
2.6 Public Health Nursing ....................................................................................................21
2.7 Psychosocial Care...........................................................................................................22
2.8 Other Practice.................................................................................................................23
2.9 Nurses as Leaders and Team Members..........................................................................23
2.10 Psychosocial Well-being of Nurses and Communities ................................................25
2.11 Summary ......................................................................................................................28
Chapter 3: Phenomenologies.................................................................................................29
3.1 Introduction ....................................................................................................................29
3.2 Things............................................................................................................................. 29
3.2.1 A stethoscope, a patient and me..............................................................................30
3.2.2 On a Background of the World ...............................................................................31
3.2.3 Epoché.....................................................................................................................32
3.3 Conscious Awareness.....................................................................................................33
3.3.1 Intentionality. ..........................................................................................................33
3.4 First Person.....................................................................................................................35
3.4.1 Being........................................................................................................................35
3.4.2 Perception................................................................................................................36

ix
3.5 Appearing .......................................................................................................................38
3.5.1 Past (retention). .......................................................................................................38
3.5.2 Now. ........................................................................................................................ 39
3.5.3 Future (pretention)...................................................................................................39
3.6 Hermeneutics in Phenomenology...................................................................................39
3.6.1 Text.......................................................................................................................... 40
3.6.2 Hermeneutic circle. .................................................................................................41
3.6.3 Historical horizons. .................................................................................................43
3.7 Summary ........................................................................................................................ 44
Chapter 4: Doing Phenomenology ........................................................................................ 45
4.1 Introduction ....................................................................................................................45
4.2 Individuals Who Have Had Experience(s).....................................................................45
4.2.1 Finding individuals..................................................................................................46
4.3 Obtaining Narrative........................................................................................................47
4.3.1 First interview. ........................................................................................................48
4.3.2 Second interview.....................................................................................................49
4.4 From Individual Narrative to a Lived-experience Description ......................................51
4.4.1 Moments..................................................................................................................51
4.4.2 Exemplars................................................................................................................52
4.4.3 A lived-experience description................................................................................53
4.5 Epoché-reduction............................................................................................................54
4.5.1 Preparatory epoché-reduction. ................................................................................54
4.5.2 Reduction proper.....................................................................................................55
4.6 Phenomenological Appraisal.......................................................................................... 55
4.7 Protection of Human Participants...................................................................................56
4.8 Summary ........................................................................................................................ 58
Chapter 5: Uncovered Moments........................................................................................... 59
5.1 Introduction ....................................................................................................................59
5.2 On the Way to a Disaster................................................................................................ 60
5.3 Prior to Starting Work ....................................................................................................72
5.4 Working a Shift in a Disaster ......................................................................................... 77
5.5 End of a Shift................................................................................................................104
5.6 Returning Home ...........................................................................................................112
5.7 Summary ...................................................................................................................... 118
Chapter 6: Lived-experience Description ..........................................................................119
6.1 Introduction ..................................................................................................................119
6.2 On the Way to a Disaster.............................................................................................. 119
6.3 Prior to Starting Work ..................................................................................................122
6.4 Working a Shift in a Disaster ....................................................................................... 123
6.5 End of a Shift................................................................................................................130
6.6 Returning Home ...........................................................................................................131
6.7 Summary ...................................................................................................................... 133
Chapter 7: A Spatial Reflection on a Lived-experience Description of Being a Nurse
Following a Disaster............................................................................................ 134
7.1 Introduction ..................................................................................................................134

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7.2 Lived-space as Shrinking Then Opening Too-wide...................................................... 135
7.2.1 Intentionality, drawing-in and shrinking............................................................... 136
7.2.2 Drawn in, looking out............................................................................................ 137
7.2.3 Wide-open, crowded. ............................................................................................ 140
7.3 Disaster Health Lived-space as Occupying, Sharing and Giving Back ....................... 141
7.3.1 Occupying. ............................................................................................................141
7.3.2 Sharing. .................................................................................................................142
7.3.3 Giving back. ..........................................................................................................143
7.4 Commentary.................................................................................................................144
7.4.1 Lived-space as shrinking then opening too-wide..................................................144
7.4.2 Disaster health lived-space as occupying, sharing and giving back. ....................144
7.5 Summary ...................................................................................................................... 145
Chapter 8: A Corporeal Reflection on a Lived-experience Description of Being a
Nurse Following a Disaster.................................................................................147
8.1 Introduction ..................................................................................................................147
8.2 Nurses’ Lived-body, When Nursing Following a Disaster..........................................148
8.2.1 Without technology and resources. .......................................................................148
8.2.2 Being autonomous................................................................................................. 150
8.3 Nurses’ Lived-body, For Patients Following a Disaster .............................................151
8.3.1 Endless lived-bodies.............................................................................................. 152
8.3.2 Injured and ill lived-bodies. ..................................................................................154
8.3.3 Death. ....................................................................................................................155
8.3.4 Psychosocial well-being........................................................................................ 156
8.3.5 Returning to the lived-body of a hospital patient..................................................157
8.4 Commentary.................................................................................................................157
8.4.1 Nurses’ lived-body, when nursing following a disaster........................................158
8.4.2 Nurses’ lived-body, for patients following a disaster ...........................................159
8.5 Summary ...................................................................................................................... 161
Chapter 9: A Communal Reflection on a Lived-experience Description of Being a
9.1 Introduction ..................................................................................................................163
9.2 With Colleagues, Being Relationally Close .................................................................164
9.2.1 Starting relationships............................................................................................. 164
9.2.2 Relational closeness as work becomes home and home becomes work. ..............165
9.2.3 Relational widening............................................................................................... 166
9.3 With Patients and Their Families, Being an Insider.....................................................166
9.3.1 Orientating to being an insider..............................................................................167
9.3.2 Being an insider and people disclosing things. .....................................................168
9.4 Being With Self ............................................................................................................169
9.4.1 By (my)self............................................................................................................169
9.4.2 Carrying an emotional burden...............................................................................170
9.4.3 Questioning the effort............................................................................................ 172
9.5 Commentary.................................................................................................................173
9.5.1 With colleagues, being relationally close.............................................................. 174
9.5.2 With patients and their families, being an insider.................................................175
9.5.3 Being with self.......................................................................................................176
9.6 Summary ...................................................................................................................... 178

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Chapter 10: A Temporal Reflection on a Lived-experience Description of Being a
10.1 Introduction ................................................................................................................179
10.2 Kairos Time Speeding Up and Condensing ............................................................... 180
10.2.1 Being rushed........................................................................................................180
10.2.2 Being busy...........................................................................................................181
10.2.3 Finding time. .......................................................................................................183
10.3 Kairos Time Slowing Down and Stretching............................................................... 183
10.3.1 Being unsure........................................................................................................184
10.3.2 Filling in time......................................................................................................187
10.4 Commentary...............................................................................................................187
10.4.1 Kairos time speeding up and condensing............................................................ 188
10.4.2 Kairos time slowing down and stretching........................................................... 188
10.5 Summary ....................................................................................................................189
Chapter 11: Being About Time ........................................................................................... 190
11.1 Summary ....................................................................................................................193
Chapter 12: Implications, Questions and Final Commentary .........................................195
12.1 Introduction ................................................................................................................195
12.2 Future Practice............................................................................................................195
12.3 Future education and professional development........................................................ 199
12.4 Future research. ..........................................................................................................201
12.5 Final Commentary......................................................................................................204
References ............................................................................................................................. 206
Appendices ............................................................................................................................ 219
Appendix A: Research and Scholarship.............................................................................219
Grants and scholarships..................................................................................................219
Book chapters.................................................................................................................220
Refereed articles in scholarly journals. ..........................................................................221
Editorials, letters and notes. ........................................................................................... 224
Extract from papers........................................................................................................224
Other articles. .................................................................................................................227
Presentations...................................................................................................................227
Keynote speaker. ........................................................................................................227
Invited/guest speaker..................................................................................................228
Refereed conferences. ................................................................................................ 230
Appendix B: Invitation and Information............................................................................235
Appendix C: Participant Interview Schedules....................................................................237
Appendix D: Example of Transcribed Participant Narrative (3.1:2–3) ............................. 239
Appendix E: Ethical Approval to Conduct Research......................................................... 240
Appendix F: Participant Consent Form..............................................................................242

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List of Tables
Table 1.1. Examples of Disaster Medical Assistance Internationally...............................8
Table 1.2. Examples of Disaster Medical Assistance Nationally......................................9
Table 4.1. Obtaining Narrative: First Interview..............................................................48
Table 4.2. Obtaining Narrative: Second Interview..........................................................50
Table 4.3. A Way of Doing Phenomenology: Moments.................................................52
Table 4.4. A Way of Doing Phenomenology: Exemplars...............................................52
Table 4.5. A Way of Doing Phenomenology: Lived-experience Description ................53
Table 4.6. Preparatory Epoché-reduction Approaches Used ..........................................54
Table 4.7. Reduction Proper Approaches Used ..............................................................55
Table 4.8. Validation Appraisal for Phenomenological Works ......................................56
Table 5.1. Moments of an Experience.............................................................................59
List of Figures
Figure 5.1. Diagrammatic representation of moments..................................................118
Figure 6.1. Diagrammatic representation of the lived experience description..............133
Figure 7.1. Media report focusing on numerical aspects of a disaster. .........................134
Figure 7.2. Diagrammatic representation of the spatial reflection................................146
Figure 8.1. Diagrammatic representation of the corporeal reflection. ..........................162
Figure 9.1. Diagrammatic representation of the communal reflection..........................178
Figure 10.1. Diagrammatic representation of the temporal reflection. .........................189
Figure 11.1. Diagrammatic representation of chronos time across moments and
existentials....................................................................................................191

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Abbreviations and Acronyms
ABC Australian Broadcasting Corporation
ADF Australian Defence Force
AusMAT Australian Medical Assistance Team
ED Emergency Department
ICN International Council of Nurses
ICU Intensive Care Unit
IV Intravenous
UN United Nations
UNISDR United Nations Office for Disaster Risk Reduction
WHO World Health Organization

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Prelude
The following anecdote is a moment from my lived experience of being a nurse in an out-of-
hospital environment following a disaster. I remember this moment as if it occurred
yesterday.
Canberra Bushfire 20031
A large bushfire was burning on the outskirts of Canberra, Australia, an inland metropolitan
city with a population of approximately 350,000 people. On Saturday 18 January 2003, the
fire extended through the city’s western suburbs. Four people died and over 500 homes were
destroyed by the fire. Hundreds of people were injured or became ill. Thousands of people
were displaced. Many people found shelter at one of four evacuation centres established
throughout the city at the request of the local government.
At the time of the bushfire, I had been a registered nurse for five months, working on the
orthopaedic trauma ward at the Canberra Hospital. I was not rostered to work at the hospital
on the day of the bushfire. I had been a volunteer with St John Ambulance Australia for 10
years. Upon hearing about the bushfire, I volunteered with St John at the nearest evacuation
centre. At the evacuation centre, I was tasked with establishing a health service and providing
health care to the people who were displaced.
At the evacuation centre, people not affected by the bushfire were streaming in with blankets,
pillows, toys and other random items for donation. People who now had no home because of
the bushfire were constantly arriving. They looked stunned and shocked by the surprise
arrival of the bushfire that had led them to be in the evacuation centre.
1 Bushfire in Canberra, Australian Capital Territory (ACT), Australia, 18 January 2003.

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I remember being called by a member of the evacuation centre staff to see an elderly man who
was complaining of a headache. While he was elderly, he was not frail. He looked well
presented. He was sitting on the floor leaning against a wall. He was surrounded by others,
strangers who had fled the destruction of the bushfire. I knelt beside the elderly man to
commence my conversation with him, at eye level. We were in a wide-open space. There was
no privacy. He whispered to me, telling me about his health history. I whispered back, trying
to solve his problem among the organised chaos of the evacuation centre.
Our conversation was specific about his life. He lived alone and cared for himself adequately.
He specifically mentioned his upbringing, family, work life and extended circle of loved ones
(past and present). His three children had moved interstate. His wife had passed away some
years ago. He focused on his home, which was under threat by fire. His home was his life and
held over 60 years of memories.
As we whispered, a stranger passed by. The stranger said that the homes in the elderly man’s
street had all burned to the ground. The elderly man looked at me. ‘I have lost my home,’ he
whispered. Our conversation quickly turned to plans for the future. He said he wanted to ‘give
up’ as it was ‘too hard to start again’.
Abruptly, I was called to assist another evacuee who was complaining of shortness of breath.
I left the elderly man to sit among strangers. When I had an opportunity to go back to see the
elderly man, he had gone.
I still wonder what happened to this elderly man. I wonder how I could have been better
prepared to care for him. How could I better prepare to help in future disasters? I wonder what
the experience of other nurses who work in the hospital environment may be like, when they

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are in the out-of-hospital environment following a disaster? How could I help other nurses
prepare for disasters?
The above wondering and questioning led me to undertake this study exploring what it may
be like being an Australian civilian hospital nurse in the out-of-hospital environment
following a disaster. This questioning led me to other research and scholarship activities
related to nursing, disasters and emergency health care. The research and scholarship
activities completed during my doctoral candidature are listed in Appendix A: Research and
scholarship.

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Chapter 1: Introduction
There are varying definitions for what constitutes a disaster. Al-Madhari and Keller (1997)
stated, ‘it must be accepted that because of different professional requirements, it is not
feasible to formulate a universal definition [of disaster] that will satisfy all practitioners’
(p. 19). For the purpose of this study, a disaster has been defined as ‘a serious disruption of
the functioning of a community or a society causing widespread human, material, economic
or environmental losses which exceed the ability of the affected community or society to cope
using its own resources’ (United Nations Office for Disaster Risk Reduction [UNISDR],
2009, p. 9). Further, the definition of a disaster for this study has adopted the definitions of
disaster from Birnbaum, Daily, O’Rourke and Loretti (2014) and Ranse and Lenson (2012).
Birnbaum et al. (2014) and Ranse and Lenson (2012) both added to the UNISDR (2009)
definition of disaster, stating that from a health perspective, a disaster overwhelms the normal
operating capacity of a health service, where an outside health response is required to restore
and maintain the normal day-to-day health services and standards of care for the disaster-
affected community.
Guha-Sapir, Hoyois and Below (2015) reported that internationally, on average, there were
384 disasters annually for the decade 2004–2013, affecting 199.2 million people and resulting
in 99,820 deaths. During this decade, three disasters led to deaths well above the annual
average: the Indian Ocean tsunami2
(226,408 deaths), Cyclone Nargis3
(138,366 deaths) and
the Haiti earthquake4
(225,570 deaths). In addition to a human cost, disasters have an
economic cost. Since the 1980s, there has been an increasing economic loss from disasters.
During the period 1980–2012, the World Bank (2013) reported an estimated US$3.8 trillion
2 Tsunami from the Indian Ocean, affecting various countries, 26 December 2004.
3 Cyclone in Myanmar, Burma, 2 May 2008.
4 Earthquake in Haiti, 12 January 2010.

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loss related to disasters. These disasters were primarily (74%) related to extreme weather
events (World Bank, 2013). Guha-Sapir et al. (2015) reported that the economic
consequences of disasters for the decade 2004–2013 are estimated at US$162.5 billion per
annum.
Disasters have long-term social and health consequences. In an integrative review of the
psychosocial impact from various natural disasters, Warsini, West, Mills and Usher (2014)
stated that post-traumatic stress disorder, depression, anxiety and stress are observed
frequently after a disaster. Following the Christchurch earthquake,5
it has been reported that
the incidences of nicotine dependence increased, as did mental health disorders such as major
depression, post-traumatic stress disorder and anxiety disorders (Fergusson et al., 2014).
Additionally, crimes such as family violence increased (New Zealand Government, 2014).
Since 9/11 in the United States,6
there has been a reported increased incidence of cognitive
impairment and possible dementia among the first responders to the disaster (Clouston et al.,
2016).
Given the significant impact that disasters have on an international scale, in 2005 the United
Nations (UN) hosted a World Conference on disaster risk reduction in Kobe, Hyogo, Japan.
An outcome of this conference was the Hyogo Framework for Action 2005–2015: Building
the Resilience of Nations and Communities to Disasters (International Strategy for Disaster
Reduction, 2007). In 2015, the UN General Assembly endorsed the Sendai Framework for
Disaster Risk Reduction 2015–2030, replacing the Hyogo Framework. The Sendai
Framework was a call to action over a 15-year period, with an expected outcome of having a
‘substantial reduction of disaster risk and losses in lives, livelihoods and health and in the
5 Earthquake in Canterbury region, New Zealand, 22 February 2011.
6 Terrorist attacks and World Trade Center collapse, United States, 11 September 2001.

6
economic, physical, social, cultural and environmental assets of persons, businesses,
communities and countries’ (p. 12). To achieve this, the framework aimed to:
Prevent new and reduce existing disaster risk through the implementation of integrated
and inclusive economic, structural, legal, social, health, cultural, educational,
environmental, technological, political and institutional measures that prevent and
reduce hazard exposure and vulnerability to disaster, increase preparedness for
response and recovery, and thus strengthen resilience (UNISDR, 2015, p. 12).
1.1 Australian Disaster Medical Assistance Arrangements
Australia has disaster medical assistance arrangements to assist in increasing the preparedness
for, and response to, disasters. These arrangements include the deployment of disaster
medical assistance teams to disaster-affected communities, nationally and internationally.
Disaster medical assistance teams are multidisciplinary health teams with staff including, but
not limited to, doctors, nurses, paramedics and pharmacists (Aitken, Canyon, Hodge, Leggat,
& Speare, 2006; Key, 1994). Disaster medical assistance teams aim to provide a coordinated
health response in an attempt to restore or maintain the health capacity of a disaster-affected
community, without placing a burden on the communities’ already stretched resources and
infrastructure (Van Hoving, Wallis, Docrat, & Vries, 2010). Therefore, disaster medical
assistance teams are often self-sufficient in terms of health resources and other amenities of
daily living such as food, water, accommodation and sanitation. In Australia, disaster medical
assistance teams may comprise either civilian government Australian Medical Assistance
Teams (AusMATs), non-government organisations, the Australian Defence Force (ADF), or a
combination of these.
When a disaster occurs in South Asia, South-eastern Asia and Oceania, the Australian
Government may be approached by the government of the disaster-affected country,
requesting disaster medical assistance. If agreed, the Australian Government may form an
AusMAT contingent consisting of civilian nurses, together with other health professionals,

7
from State- and/or Territory-based disaster medical assistance teams. According to Norton
and Trewin (2011), AusMATs have been deployed on a number of occasions such as ‘the
Javanese Earthquake,7
the Samoan Tsunami8
and the Christchurch earthquake . . . [and] the
Pakistan floods’ (p. 9).
Disaster medical assistance teams are well established in Australian non-government
organisations such as the Australian Red Cross and St John Ambulance Australia. These
disaster medical assistance teams are deployed interstate following disasters in Australia. For
example, St John Ambulance Australia has deployed nursing members to disasters such as the
Black Saturday and Victorian bushfires9
(Ranse & Lenson, 2012; Ranse, Lenson, & Aimers,
2010) and Queensland extreme weather events.10
Nurses are engaged by the ADF in both career and reservist capacities to provide health
support activities to the Australian Army, the Royal Australian Navy and the Royal Australian
Air Force. In the past, ADF nursing reservists have assisted in disasters such as the Aitape
tsunami11
(Pearn, 1998; Taylor, Emonson, & Schlimmer, 1998), Bali I bombing12
(Hampson,
Cook, & Frederiksen, 2002), and the Indian Ocean tsunami (Chambers, Campion, Courtenay,
Crozier, & New, 2006). More recently, the ADF has provided logistical support to AusMAT
civilian government contingents, rather than deploying ADF health-specific disaster medical
assistance teams.
7 Earthquake in Yogyakarta, Indonesia, 27 May 2006.
8 Earthquake and Tsunami, Samoa, 29 September 2009.
9 Bushfires in Victoria, Australia, February 2009.
10 Flooding and extreme weather events, Queensland, Australia, December 2010 and January
2011.
11 Tsunami in Aitape, Papua New Guinea, 17 July 1998.
12 Bombing in Kuta, Island of Bali, Indonesia, 12 October 2002.

8
Some of the historically notable disasters in Australia requiring medical assistance have
included Cyclone Tracy13
(Gurd, Bromwich, & Quinn, 1975; Mahajani, 1975), the Granville
rail disaster14
(Christopher & Selig, 1977), the Ash Wednesday bushfires15
(Bacon, 1983;
Cox, 1997) and the Thredbo landslide16
(Harris, 1997). More recently, there have been a
number of examples, both internationally (see Table 1.1) and nationally (see Table 1.2), in
which Australian disaster medical assistance teams have been deployed.
Table 1.1. Examples of Disaster Medical Assistance Internationally
Disaster Year
Fiji Tropical Cyclone Winston 2016
Vanuatu Tropical Cyclone Pam 2015
Philippines Typhoon Haiyan 2014
Christchurch earthquake 2011
Pakistan floods 2010
Pacific tsunami 2009
Java earthquake 2006
Bali bombings II 2005
Indian Ocean tsunami 2004
Adapted from the Australian Government Department of Health (2011).
13 Cyclone in Darwin, Northern Territory, Australia, 24 December 1974.
14 Train accident in Granville, NSW, Australia, 18 January 1977.
15 Bushfires in South-eastern Australia, 16 February 1983.
16 Landslide in Thredbo, NSW, Australia, 30 July 1997.

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Table 1.2. Examples of Disaster Medical Assistance Nationally
Disaster Year
Tropical Cyclone Yasi 2011
Queensland and Victorian Floods 2011
SIEV sinking near Christmas Island 2010
SIEV explosion near Ashmore Reef 2009
Victorian bushfires 2009
Adapted from the Australian Government Department of Health (2011).
1.2 Australian Nurses in the Out-of-hospital Environment Following a
Disaster
Tables 1.1 and 1.2 note the instances of deployment of Australian civilian nurses as part of
disaster medical assistance teams in the out-of-hospital environment following a disaster.
Despite multiple deployments of nurses in disaster medical assistance teams, the literature
pertaining to Australian civilian nurses in the out-of-hospital environment is scant, both
nationally and internationally. The literature that does exist concentrates superficially on
nurses’ roles in single disastrous events. For example, following Cyclone Tracy, nurses were
described as assisting in evacuation centres (O’Shea, 1975) and establishing community first
aid posts (Gurd et al., 1975). Following the Ash Wednesday bushfires, nurses were described
as being members of the resuscitation teams (Bacon, 1983) and providing first aid in the
community (Cox, 1997). Following the Indian Ocean tsunami, nurses were described as
staffing the operating theatre and being responsible for the sterilisation and packaging of
equipment (Bridgewater et al., 2006).

10
The literature includes personal reflective descriptive accounts from nurses. In an account of
the Katherine Floods,17
Serghis (1998) stated that nurses assisted in evacuation camps that
were established with the assistance of the ADF following the evacuation of the local
hospital. In the evacuation camps, nurses participated in wound care and implemented
strategies to mitigate the spread of infectious diseases. In a self-reflective editorial on
assisting as part of a disaster medical assistance team following the Victorian bushfires,
Martin (2009) focused on the implication of being a nurse practitioner and the need to explore
the role of nurse practitioners in disaster medical assistance teams. In a statement to the 2009
Victorian Bushfire Royal Commission, registered nurse Ms Katherine Harland stated that she:
joined other volunteer nurses who had set up a first aid station, sought assistance on
local radio for medical support and medical supplies, and liaised with the CFA
[Country Fire Authority of Victoria] and Victoria State Emergency Service to identify
first aid response needs and locations. (Parliament of Victoria, 2010, p. 327).
Other literature is descriptive of single events. In a survey of nurses who assisted in the out-
of-hospital environment during the Black Saturday and Victorian bushfires, the nursing role
was reported as including clinical activities, command roles and administration (Ranse et al.,
2010). In a follow-up to that research, 11 nurses were interviewed about their role in the
Black Saturday and Victorian bushfires (Ranse & Lenson, 2012). These nurses described their
roles as being providers of clinical care, a psychosocial supporter of both relief workers and
the disaster-affected community, coordinators of care and problem solvers.
1.3 Problem Statement
Disasters occur internationally with significant short- and long-term human and economic
costs. Nurses who respond as part of a military humanitarian response may have a different
experience to Australian general Registered Nurses (Division 1), who primarily work as
17 Floods in Katherine, Northern Territory, Australia, January 1998.

11
clinicians in a hospital and have deployed following a disastrous event as part of a non-
military organisation, association or group or health disaster medical assistance team.
Therefore, this study focused on civilian nurses rather than military nurses.
The Australian literature relating to nurses’ experiences of the out-of-hospital environment
following a disaster has been mostly simply descriptive, personal reflections and based on
single disastrous events. To enhance the preparedness for the response and recovery in
disaster-affected communities, an in-depth understanding of Australian civilian nurses’
experiences of the disaster context is required. Until now, there has been no exploration in the
Australian disaster nursing literature of the nurses’ experiences from a phenomenological
perspective, particularly by phenomenological reflection using the preparatory epoché-
reduction and reduction proper overlaying the phenomenological existentials of ‘lived-space’,
‘lived-body’, ‘lived-relations’ and ‘lived-time’. Such an approach would provide insight into
understanding an experience of what it may be like being a civilian hospital nurse in the out-
of-hospital environment following a disaster. This understanding could inform future practice,
future education and professional development and future research. This would be aligned
with the goal of the Sendai Framework to ‘reduce existing disaster risk through . . .
increase[d] preparedness for response and recovery, and thus strengthen resilience’ (UNISDR,
2015, p. 12).
The research question for this study was ‘what may it be like being an Australian civilian
hospital nurse as part of a disaster medical assistance team in the out-of-hospital environment
following a disaster’?

12
1.4 Structure of this Thesis
The prelude to this study presented a first-person anecdote of my experience of being a nurse
in an out-of-hospital environment following the Canberra Bushfire. This anecdote focused on
a specific moment in the disaster response that led to my programme of research and
scholarship relating to emergency health care and ultimately, to this study of Australian
civilian hospital nurses’ lived experience of the out-of-hospital environment following a
disaster.
This introduction chapter has outlined the international impact of disasters from a human and
economic perspective. Historical and current Australian disaster medical arrangements have
been discussed, noting that although Australian nurses respond as part of disaster medical
assistance teams in the out-of-hospital environment following a disaster, the literature
regarding their experiences has been based on personal reflective accounts and simple
descriptions from single disastrous events. The purpose of this study has been identified and
the research question underpinning the study has been presented.
The literature review in Chapter 2 presents what is known about the experience of nurses in
the out-of-hospital environment following a disaster, from an international perspective. This
chapter identifies that there is a great deal known about nursing following a disaster.
However, the literature does not include the experience of Australian civilian hospital nurses
in the out-of-hospital environment following a disaster, from a phenomenological perspective
of lived-space, lived-body, lived-relationships and lived-time, from multiple disasters.
Chapter 3 describes a variety of phenomenological theoretical perspectives. This is
approached from the perspective of phenomenology being concerned with the essence of

13
things as they are appearing in the conscious awareness of the first person. The relationship
between phenomenology and hermeneutics are discussed.
In Chapter 4, the previously presented phenomenologies and associated theoretical
underpinnings are applied to this study as a method. This chapter outlines a practical way of
‘doing phenomenology’ as it is applied to the research question for this study, particularly the
preparatory epoché-reduction and reduction proper as a key method.
Chapter 5 integrates the participant narratives with descriptive moments in an experience for
nurses in the out-of-hospital environment following a disaster. The identification of moments
of what it may be like being a nurse in an out-of-hospital environment following a disaster is
supported by exemplars of participant narrative. The narrative is placed against summary
anecdotes using the phenomenological I. The summary anecdotes lead to a ‘lived-experience
description’ in Chapter 6.
Following the lived-experience description in Chapter 6, a series of reflections are presented
in Chapters 7, 8, 9 and 10 overlaying the phenomenological existentials with the uncovered
moments of the lived-experience description. These reflections go beyond the physical,
touchable life-world of a nurse and delve into what it may be like for a nurse existentially.
The focus of these reflections is on being a civilian hospital nurse in the out-of-hospital
environment following a disaster, from a lived-space (Chapter 7), lived-body (Chapter 8),
lived-relationships (Chapter 9) and lived-time (Chapter 10) perspective. A preparatory
epoché-reduction and reduction proper guide these reflections on being a nurse in an out-of-
hospital environment following a disaster from the previously presented lived-experience
description. The commentary provides a discussion about these observations from an eidetic
position.

14
Chronos time emerges as a strong backdrop to the life-world of a nurse in Chapter 11.
Chronos time intersects with the previously presented uncovered moments in Chapter 5, the
lived-experience description in Chapter 6 and phenomenological existential reflections in
Chapter 7, 8, 9 and 10. As chronos time emerges in Chapter 11, the experience of nurses is
further uncovered as an experience that is about time.
Finally, Chapter 12 presents the implications, questions and final commentary, outlining the
key implications and questions for this study relating to future practice, future education and
professional development, and further research. The importance of this study is discussed, in
particular highlighting its uniqueness and the contribution it makes in enhancing the future
experience of Australian hospital nurses as part of a disaster medical assistance team in the
out-of-hospital environment.

15
Chapter 2: Literature Review
2.1 Introduction
This chapter provides a review and critical appraisal of the literature pertaining to the
experience of nurses in the out-of-hospital environment following a disaster. The question
guiding this literature review was ‘what is known from the literature about hospital nurses
experiences of the out-of-hospital environment following a disaster?’ This review was
undertaken systematically at the commencement of this study. Databases and search engines
for this review were OvidSP (Ovid Technologies; New York, New York USA; MEDLINE
[Medline Industries, Inc.; Mundelein, Illinois USA), PsycINFO (American Psychological
Association; Washington DC, USA), and DARE (Rutgers University Libraries; New
Brunswick, New Jersey USA), CINAHL (EBSCO Information Services; Ipswich,
Massachusetts USA), Pubmed (National Center for Biotechnology Information; Bethesda,
Maryland USA), and Scopus (Elsevier; Amsterdam, Netherlands) and Google Scholar. The
search strategy included different combinations of keywords and Medical Subject Headings
terms that were relevant to the research question, such as ‘disasters’, ‘emergencies’,
‘emergency medicine’, ‘emergency shelter’, ‘experience’, ‘life experiences’, ‘mass casualty
incidents’, ‘nurse’, ‘nurses’, ‘nursing’, ‘out-of-hospital’, ‘relief work’ and ‘rescue work’. No
date restrictions were placed on this search.
In addition to undertaking this review at the beginning of this study, this literature review was
undertaken iteratively throughout the study using citation alerts to identify contemporary
works. Further, this review used manuscript reference lists in a snowballing manner to
identify possible literature for inclusion. This review included literature about real-world
disaster events that included nurses as participants, where nurses were in the out-of-hospital
environment following a disaster. It excluded literature relating to the experience of nurses in

16
the hospital environment following a disaster (rather than the out-of-hospital environment),
such as literature from the Nepal earthquake18
(World Health Organization [WHO], 2015), the
Christchurch earthquake (Lyneham & Byrne, 2011) and Cyclone Yasi19
(Hayes, 2011; Little
et al., 2012; McArdle, 2011). Additionally, this literature review focused on papers on real-
world events, rather than on discussion or theoretical papers about possible or hypothetical
disasters that had not occurred.
The literature included in this review has been divided, using a heuristic approach, into
categories such as nurses’ clinical experience, nurses’ disaster medical assistance team
affiliations, nursing practice, nurses as leaders and team members, and the psychosocial well-
being of nurses and communities.
2.2 Nurses’ Clinical Experience
Nurses who have responded following a disaster have had varied hospital clinical experience.
In a descriptive study of nurses who formed a disaster medical assistance team in the out-of-
hospital environment following the Wenchuan earthquake,20
the most frequently reported
hospital clinical background of nurses was from the operating theatre environment (n = 8,
33.3%) (Yin et al., 2012). All nurse (n = 10, 100%) in another study following the Wenchuan
earthquake had clinical experience in either emergency or perioperative environments (Yang,
Xiao, Cheng, Zhu, & Arbon, 2010). In describing the clinical experience of nurses from
research regarding a Swedish tram and train disaster,21
Suserud and Haljamae (1997) reported
that the majority of nurses (n = 11, 68.8%) had an intensive care or emergency nursing
background.
18 Earthquake in Nepal, April–May 2015.
19 Tropical Cyclone in Queensland, Australia, 3 February 2011.
20 Earthquake in Wenchuan County, China, 12 May 2008.
21 Tram and train disaster, Sweden, date unknown.

17
In addition to nurses having predominantly clinical experience in emergency, intensive care
or perioperative environments, nurses responding to some disasters had predominantly
medical or surgical clinical experience. Following the Jiji earthquake,22
the nurses that
assisted in the disaster response were medical (n = 14, 30%), followed by surgical (n = 9,
20%), intensive care (n = 9, 20%) and emergency (n = 8, 17%) nurses (Shih, Liao, Chan, Duh,
& Gau, 2002). Similarly, in a survey of nurses who assisted in the Black Saturday and
Victorian bushfires, Ranse et al. (2010) reported that the clinical experience of nurses
included the acute medical (n = 9, 37.5%) and surgical (n = 8, 33.3%) environments. A
smaller number were from the emergency department (ED) (n = 4, 16.7%), perioperative
(n = 1, 4.2%) and intensive care (n = 1, 4.2%) environments.
The previous disaster experience of nurses varied from assisting in multiple previous disasters
as part of a disaster medical assistance team to having no prior disasters experience. Nursing
members of St John Ambulance Australia who responded following the Black Saturday and
Victorian bushfires answered a survey indicating that they all (n = 24, 100%) had previous
out-of-hospital clinical experience, with most (n = 16, 67%) reporting that they had previous
disaster experience as a nurse (Ranse et al., 2010). On average, nurses in this research had
assisted in two previous disasters (Ranse et al., 2010). In a study of nurses who assisted
following the Sweden tram and train disaster, most (n = 10, 62.5%) had out-of-hospital
nursing experience, particularly at other disasters and emergencies (Suserud & Haljamae,
1997). Conversely, all nurses (n = 13, 100%) in a qualitative study relating to the Bam
earthquake23
had no previous disaster experience (Nasrabadi, Naji, Mirzabeigi, & Dadbakhs,
2007). Dickerson et al. (2002) observed that nurses with previous disaster experience prior to
22 Earthquake in Nantou County, Taiwan, 21 September 1999.
23 Earthquake in Bam Province, Iran, 26 December 2003.

18
assisting in the events following 9/11 experienced less frustration and anxiety than those who
were having their first disaster experience.
2.3 Nurses’ Disaster Medical Assistance Team Affiliation
As established in the introduction, nurses respond following disasters as members of disaster
medical assistance teams. These teams may be government civilian, non-government
organisations or defence force disaster medical assistance teams. Nurses who respond
following a disaster as part of a disaster medical assistance team have a sense of being
prepared and supported. Ketchie and Breuilly (2010) observed that nurses in a national
disaster medical assistance team following the Haiti earthquake had a sense of feeling
prepared for their work. Similarly, following 9/11, Dickerson et al.’s (2002) hermeneutic
phenomenological study observed that nurses who were affiliated with a disaster medical
assistance team were supported with access to formal organisational leadership and role
delineation. This would be expected because disaster medical assistance teams provide a
governance structure. Conversely, nurses deploying without disaster medical assistance team
affiliation expressed frustration in their inability to assist to their perceived full potential
(Dickerson et al., 2002).
Nurses may decide to respond following a disaster independent of an established disaster
medical assistance team, without an official call or invitation for their assistance. Following
the Christchurch earthquake, nurses who were in the city attending a conference made
themselves available at first aid posts (Chiarella, 2011). Learning of the devastation in New
York City immediately following the events of 9/11 via television broadcasts, Gatto (2002)
self-presented to offer her assistance. Similarly, following the Puerto Rico floods,24
after the
24 Floods in Puerto Rico, 29 September 1985 onwards.

19
media announced to the community that an evacuation centre had been established, nurses
and nursing students self-presented to assist (Rivera, 1986).
As nurses live and work within the general population in disaster-affected communities, it is
reasonable to expect them to decide to assist without an official invitation and to do so
independently of any disaster medical assistance team affiliation. However, the experience of
nurses who respond following independently from an established disaster medical assistance
team may be different from nurses who are affiliated with a disaster medical assistance team.
2.4 Nursing Practice
Nursing practice following a disaster can be varied, based on the type of disaster, a nurse’s
country of origin and a nurse’s scope of practice. This literature review notes that following a
disaster, nursing practice included assessing and managing various injuries and illnesses,
aspects of public health nursing, psychosocial care and other nursing practices. However,
there is a lack of complexity in the published literature because it has originated from single
events and the authors, commonly reflecting on their own experience of being in the disaster,
have provided a superficial account of their nursing practice.
Following a disaster, nurses are required to use their clinical decision making and rely less on
well-developed protocols or guidelines to guide their nursing practice. For example, Gatto
(2002) stated that following 9/11:
There was no policy, no procedure, no one to report to, or get report[s] from. There
was no routine, no schedule . . . it was nursing knowledge and skill—the true nursing
instinct you find when you’re faced with a totally unknown experience (p. 5).
This was similar to the experience of nurses following the Bam earthquake, who described the
out-of-hospital disaster environment to be different from the hospital environment, lacking

20
guidelines or protocols to assist in their decision making (Nasrabadi et al., 2007). Practising
without policies and procedures may be normal in a disaster because the situation of
practising in a disaster would be unfamiliar to most nurses.
2.5 Injury and Illness Assessment and Management
Nurses provide care to patients with minor injuries following disasters. Following the Black
Saturday and Victorian bushfires, nurses described primarily treating minor injuries and
wounds (Ranse & Lenson, 2012). Similarly, when comparing the two real-life disasters in the
Sweden tram and train disasters, nursing practice primarily involved the care of patients with
minor injuries (n = 126, 66.3%) rather than severe injuries (n = 42, 22.1%) or deceased
patients (n = 22, 11.5%) (Suserud & Haljamae, 1997). Managing cuts, bruises and wounds
were activities undertaken by nurses following the Katherine floods (Serghis, 1998). First aid
was suggested as an essential component of care by nurses following the Puerto Rico floods
(Rivera, 1986). Likewise, minor injuries requiring band-aids were required following
Hurricane Katrina25 (Weeks, 2007). Following the Texas tornado, Brown (1989) recalled
undertaking minor wound assessment and management. Managing minor injuries may be
predominant following a disaster because people who are impacted directly by the disaster
may either die or have minor injuries.
Nurses following a disaster undertake the management of chronic conditions such as
hypertension and diabetes. Following the Black Saturday and Victorian bushfires, monitoring
chronic conditions such as hypertension was part of a nurse’s role (Ranse & Lenson, 2012).
Similarly, following the Puerto Rico flood and Jiji earthquake, nurses managed cases of
chronic illnesses such as hypertension and diabetes, stating that this aspect of nursing was an
25 Tropical cyclone, south-east United States, August 2005.

21
important activity (Rivera, 1986; Shih et al., 2002). In addition, nurses participate in
individual patient medication management for chronic conditions. They problem solve with
patients to determine the type of medications a patient normally takes, and the dose and
frequency, and determine avenues to access medications for patients. Following the Black
Saturday and Victorian bushfires, nurses worked with patients to determine their medication
requirements and how they could access those medications (Ranse & Lenson, 2012). Nurses
who assisted after the Texas tornado reported that patients presented with a lack of health
supplies such as medications (Brown, 1989). Managing chronic health conditions following a
disaster would be expected because many people in any given population have chronic health
conditions. However, beyond describing the literature regarding injury and illness assessment
and management, the literature lacks any in-depth understanding of what it may be like being
a nurse in an out-of-hospital environment following a disaster in caring for people who have
injuries and illnesses.
2.6 Public Health Nursing
Following a disaster, nurses undertake public health roles such as communicable disease
management and providing opportunistic vaccinations. Nurses were involved in the
management of infectious diseases (e.g., gastroenteritis) that occurred after the Puerto Rico
floods (Rivera, 1986) and Katherine floods (Serghis, 1998). This was particularly evident
when evacuation centres were in venues with compromised water supplies, failed sewerage
systems and minimal toilet facilities (Rivera, 1986). Following the Great Eastern earthquake
and tsunami,26
nurses undertook public health surveillance activities in evacuation centres in
Japan (Kako, Ranse, Yamamoto, & Arbon, 2014). Additionally, at evacuation centres during
26 Earthquake and tsunami in Japan, 11 March 2011.

22
the Puerto Rico floods, nurses provided opportunistic vaccinations for infectious diseases
(Rivera, 1986).
2.7 Psychosocial Care
Nurses provide psychosocial assessments and care to people in disaster-affected communities.
Disasters are a known cause for mental illness, such as various forms of depression, post-
traumatic stress disorders and elevated suicide risk (Warsini, Mills, & Usher, 2014). Evacuees
from Hurricane Katrina were assessed by nurses for both their physical and psychosocial
well-being (Weeks, 2007). Similarly, following the Puerto Rico floods, a psychological
assessment was carried out by nurses on all people presenting to evacuation centres and found
‘depression, anxiety, loneliness, insecurity and above all the concept of loss’ (Rivera, 1986,
p. 141).
People in a disaster-affected community discuss their thoughts, feelings and emotions related
to being in a disaster openly with nurses. In researching both nurses and those affected by the
Ash Wednesday bushfire, Cox (1997) suggested that those affected by the disaster disclosed
things to nurses that they would not normally disclose to a stranger. Nurses who lived and
worked external to the disaster-affected community were accepted in the community as
‘insiders’ rather than being seen as ‘outsiders’. Nurses provided psychosocial caring to people
affected by the tram and train disaster in Sweden (Suserud & Haljamae, 1997), as well as
following the Queensland extreme weather events (Hasleton, Allan, Hegner, Kerley, &
Stevens, 2013). Similarly, following the Black Saturday and Victorian bushfires, nurses stated
that patients presented for clinical assessment and management of minor ailments and during
these consultations patients wanted to talk about their experiences of being in the disaster
(Ranse & Lenson, 2012).

23
2.8 Other Practice
Nurses refer patients to other health services. For example, following the Texas tornado, some
patients were without their dentures and hearing aids and nurses were able to link patients
with services to obtain such adjuncts (Brown, 1989). Similarly, in identifying a psychosocial
referral need for some patients following the Puerto Rico floods and Ash Wednesday
bushfire, nurses linked patients with local mental health services (Cox, 1997; Rivera, 1986).
Some infrequent nursing practice reported following a disaster includes delivering babies,
performing cardiopulmonary resuscitation, tracheal intubation and thoracic drainage. The
delivery of babies was reported following the Haiti earthquake (Ketchie & Breuilly, 2010)
and participating in cardiopulmonary resuscitation of an evacuee in an evacuation centre was
reported following Hurricane Katrina (Weeks, 2007). Additionally, Yin et al. (2012) reported
that tracheal intubation (n = 4, 16.7%) and thoracic drainage (n = 1, 4.2%) were performed
occasionally by nurses.
It is evident that the scope of practice for nurses differs between countries. For example,
Australian nurses are unlikely to perform tracheal intubation or thoracic drainage. Because of
this variation in nursing scope of practice between various countries, it was reasonable in this
research to first study the experience of one nursing population, to better understand the
experience of being a nurse in an out-of-hospital environment following a disaster, before
exploring a multinational experience.
2.9 Nurses as Leaders and Team Members
Nurses are leaders of health teams following a disaster. Some nurses (n = 16, 66.7%) who
assisted following the Black Saturday and Victorian bushfires undertook a leadership role in
the Emergency Operations Centre, such as commander (n = 4, 16.7%), liaison with other
organisations (n = 2, 8.3%) or organising logistics (n = 2, 8.3%) (Ranse & Lenson, 2012).

24
Nurses with an intensive care or emergency nursing background are more likely to undertake
a clinical leadership role than are other nurses. For example, during the Sweden tram and train
disaster, half of the intensive care and emergency nurses (n = 8/16, 50%) undertook a clinical
leadership role, while no other nurses undertook a leadership role at these events
(n = 0/16, 0%) (Suserud & Haljamae, 1997). However, following some disasters, nurses
experience a sense of poor leadership from a health perspective, which results in nurses
adopting an unplanned or spontaneous leadership role. For example, a lack of leadership was
noted at evacuation centres following 9/11 (Gatto, 2002). Similarly, a lack of leadership was
noted on arrival to evacuation centres following the Puerto Rico floods (Rivera, 1986). Weeks
(2007) stated that in Texas following Hurricane Katrina, although she did not think she was
necessarily the best person to be in a leadership role, she undertook it because someone
needed to take charge.
Following a disaster, working in teams enhances collegiality. Disasters result in a ‘coming
togetherness’, a mateship between nurses that did not necessarily exist prior to the disaster
(Dickerson et al., 2002). Shih et al., (2002) reported that building stronger collegial
relationships and getting to know colleagues better, in a way that would not have occurred if
they were not deployed together, was a positive attribute of being in a disaster. However,
being in a team is not always a positive experience for nurses, with a lack of teamwork and
poor organisation resulting in a negative experience. Nurses from the Bam earthquake
suggested that there was an overall lack of teamwork, particularly during the early stages of
the disaster. This lack of teamwork was made more noticeable when disaster medical
assistance teams from other countries arrived, with a lack of coordination in the disaster
assistance efforts (Nasrabadi et al., 2007). Similarly, poor organisation resulted in a negative
experience for some nurses (n = 3, 18.8%) involved in the Sweden tram and train disaster
(Suserud & Haljamae, 1997).

25
Teamwork and cooperation occurs between disaster medical assistance teams, resulting in
nurses sharing equipment. For example, following the Wenchuan earthquake, nurses shared
their equipment among different disaster medical assistance teams, as damaged transport
infrastructure prevented all the desired equipment being available at the disaster site (Yang,
Xiao, et al., 2010). Similarly, following Hurricane Katrina, the evacuation centres that were
established in nearby cities lacked items such as first aid supplies, beds and linen. The sharing
of equipment between nurses at the evacuation centre and local hospitals resulted in low-
acuity patients being able to remain at the evacuation centre, rather than being transported to
hospital (Weeks, 2007) However, a lack of corporation between organisations can result in
nurses improvising in providing care for patients. In the Wenchuan earthquake, nurses in a
disaster medical assistance team from outside Wenchuan County had to learn about the local
health system, vulnerable community members and food and water resources in the region
because agencies were unwilling to coordinate (Yang, Xiao et al., 2010). In addition, the
nurses were required to improvise to provide adequate care for patients, such as using
intravenous set lines as urinary catheters to manage patients with urinary retention.
2.10 Psychosocial Well-being of Nurses and Communities
Disaster work is physical. This was exemplified by nurses following the Wenchuan
earthquake, who recalled the requirement to walk more than nine hours to the disaster area
carrying a backpack weighing 30 kg (Yang, Xiao et al., 2010). This was a necessity due to
damaged transport infrastructure that did not permit the movement of vehicles to transport
either human or material resources. The nurses from this disaster expressed having a sense of
physical unpreparedness for disaster work in the out-of-hospital environment. In addition to
the need to be physically prepared to carry heavy items over long distances, nurses who assist
following disasters may become physically exhausted as they may work more hours in a day
when compared to the day-to-day non-disaster hospital environment. Nurses in disaster

26
responses following the Ash Wednesday bushfires and the Izmit earthquake27
stated that they
worked more hours per day than their usual hospital working hours (Cox, 1997; Margalit et
al., 2002).
Nurses who assist following a disaster need to be prepared psychosocially. Nurses involved in
the response to the Wenchuan earthquake said they felt unprepared psychosocially (Yang,
Xiao et al., 2010). Nurses involved in the response to the Ash Wednesday bushfires said they
were ill-prepared from a psychosocial perspective and described being overwhelmed (Cox,
1997).
Nurses’ experiences in a disaster from the perspective of caring for a deceased or dying
patient is different to an experience of death and dying in the hospital environment, as death
in a disaster is on a large scale. One nurse recalled seeing numerous bodies lying on the
ground, with family members leaning over them, crying for long periods (Shih et al., 2002).
Following the Wenchuan earthquake, nurses experienced the sight of many people dying and
seeing large numbers of corpses (Yang, Xiao et al., 2010). Yang, Xiao et al. (2010) recounted
a story from a nurse who held the hand of a young girl who died while being rescued from a
collapsed building. This nurse could not sleep for long periods once her deployment ended.
Images in the media do not emphasise the overwhelming emotional devastation witnessed by
nurses following a disaster. While assisting following the 9/11 disaster, nurses witnessed the
emotions of the disaster-affected community members and relief workers (Dickerson et al.,
2002). Brown (1989) noted that while images on television give some insight into the disaster
environment (e.g., the Texas tornado), it does not prepare a person for the first-hand
experience of witnessing the overwhelming sense of devastation and grief of those affected by
27 Earthquake in the Marmara Region, Turkey, 19 October 1999.

27
the disaster. Similarly, Ketchie and Breuilly (2010), who responded following the Haiti
earthquake, stated that the devastation seen on television and in the media did not capture the
destruction and large numbers of displaced people resulting from the disaster.
The emotional effects of assisting in a disaster are not always negative. Serghis (1998)
reported that the Clinical Nurse Consultant of Katherine Hospital noticed that some staff were
not coping with the events of the Katherine floods, whereas others seemed to be fine and
continued to work. Some nurses may experience personal and professional growth from being
in a disaster and have a sense of joyfulness, meaningfulness and privilege for caring for
people. For example, some nurses who assisted following the Bam earthquake reported a
sense of joyfulness because of their experience (Nasrabadi et al., 2007). Similarly, Rivera
(1986), in a personal account of the Puerto Rico floods, described a sense of personal and
professional growth because of their experience. Both personal and professional growth was
described by nurses following the Wenchuan earthquake, with caring for others providing a
sense of meaning (Yang, Xiao et al., 2010), as nurses felt privileged to be able to assist those
affected by the disaster (Shih et al., 2002).
Nurses engage in humour to cope in a disaster. After the Christchurch earthquake, humour
was apparent among survivors and nurses (Chiarella, 2011). It was important that nurses did
not lose their humour, as it was a technique for remaining focused on providing clinical care
(Serghis, 1998). However, following Ash Wednesday, humour was kept within nursing and
not shared with the wider community, as it was considered to be ‘black humour’, which
seemed to be acceptable internally for coping with the disaster but would be unacceptable
externally (Cox, 1997).

28
2.11 Summary
This literature review has highlighted that the experience of nurses in the out-of-hospital
disaster environment following a disaster mostly consists of descriptive accounts from single
disastrous events. Single descriptive accounts lack the depth to provide a deeper
understanding of what it may be like being a nurse in an out-of-hospital environment
following a disaster. The perspectives of this experience from various disaster types could
provide broader insights into the singularities of disasters. A phenomenological perspective
that uncovers a possible or likely experience from multiple disasters, from an existential
perspective, is absent from the literature. Further, the literature review has demonstrated that
the Australian literature pertaining to the real-life experience of nurses assisting in out-of-
hospital disasters is scant. It is important to understand the lived experience of Australian
civilian nurses following a disaster in the out-of-hospital environment as part of a disaster
medical assistance team because it may differ experientially from an international nursing
experience. To explore what it may be like being an Australian civilian nurses in the out-of-
hospital environment following a disaster as part of a disaster medical assistance team, a
phenomenological approach would be appropriate. The next chapter provides an exploration
of phenomenologies from a theoretical perspective, to form the basis of this study.

29
Chapter 3: Phenomenologies
3.1 Introduction
Phenomenology is concerned with the way a person experiences things within the world
(Heidegger, 1953/2010; Husserl, 1900/2001; Merleau-Ponty, 1945/2002). Phenomenology is
not concerned with finding answers to the life-world experiences. Rather, phenomenology
may raise more questions and give new insights and understandings about an experience that
is being explored. Phenomenology is steeped in an attitude of wonder, to give insight into
what it may be like to have a particular experience (van Manen, 2013). In the case of this
study, what it may be like being an Australian civilian hospital nurse in the out-of-hospital
environment following a disaster. Therefore, phenomenology is concerned with the essence of
things as they are appearing in the conscious awareness of the first person.
Four key aspects of phenomenology are explored in this chapter: things, conscious awareness,
first person and appearing. Additionally, hermeneutics and its overlapping relationship
phenomenology are discussed.
3.2 Things
Things in the world have properties. Physical or material things are objects with concrete
properties. Things often have meaning and purpose. For example, if a piece of plastic joined
to metal is placed on a desk, it might be observed to be a piece of plastic joined to metal.
However, if this plastic has a particular shape, such as cylindrical Y-shaped tubing, it might
be more than ‘just’ a piece of plastic joined to metal. If the bottom of the Y-shaped plastic is
round, double-sided and metallic in nature and the top of the Y-shaped tubing has two small,
soft pieces of plastic on either side, it might resemble a recognisable thing. It might be
recognised that this thing is a stethoscope. If someone picks up the stethoscope from the desk,

30
they can note other properties, such as the length of the tubing or weight of the stethoscope,
that may not have been known until the person holds the stethoscope in their hand or they
place the stethoscope around their neck. The tubing might be long, short or just right for the
purpose for which they wish to use it.
It is the uniqueness or singularity of the properties of a thing that gives the thing its
‘thingness’, the what its ‘whatness’ or being its ‘beingness’. These unique properties are
referred to as the essence of a thing (van Manen, 2014b). If the essence of a thing is removed,
the thing can no longer be recognised as that thing, but instead is something else. Therefore,
the essences are the uniqueness or singularity of a thing. As a simple example, if the Y-shaped
tubing from a stethoscope is removed and only the round, double-sided metallic piece
remains, it may not be recognisable as a stethoscope.
3.2.1 A stethoscope, a patient and me.
Ranse (2015) described the phenomenological aspect of a stethoscope as follows:
The anecdote below provides an insight into the phenomenological natural attitude of
the stethoscope and what it may be like to experience a stethoscope as a nurse or as a
patient. A stethoscope is a thing that has concrete properties, purpose and meaning.
The stethoscope holds purpose and meaning for me as nurse.
I walk into the hospital and place my stethoscope around my neck. The stethoscope
turns me from a layperson into a nurse, with tools ready-at-hand. My stethoscope is
ready to be used for a particular purpose, auscultation. When I use my stethoscope I
am interested in the patient as a whole, but I am concentrating on the sound that is
reverberating through the tubing of the stethoscope. I am concentrating on the
intricacies of the sound that is being listened to, such as the lub-dub of a heartbeat.
Whilst the stethoscope amplifies a sound of interest, I find it difficult to hear the
conversations of those nearby or the sound of monitors alarming in the distance.
External sounds are reduced to a muffle. I need to concentrate, I need to listen. The
stethoscope allows for the unheard to be heard. The unheard provides insight into the
patient’s condition. I hear what the patient themselves do not hear; I know what the
patient themselves do not know. My auditory insight provides knowledge about the
patient’s condition for the sake of planning and evaluating care.

31
The patient’s experience of the stethoscope as a thing may be somewhat different from
that of a nurse. Perhaps patients have an expectation of a nurse with a stethoscope
around their neck? That a nurse has a certain level of clinical knowledge? The
stethoscope partners a nurse and patient in a collaboration of care.
As a patient, I willingly lift my shirt for a nurse to use their stethoscope. I may not
always be willing; on occasions, I am hesitant to lift my shirt. The stethoscope may be
cold. The stethoscope reminds me of my previous illness. The illness of a loved one. It
may evoke a stressful moment in life. I cannot hear my own heartbeat; it is only heard
by a nurse that uses the stethoscope.
The young child or confused elderly may not want the stethoscope near them. They
may use their hand to brush away the stethoscope. Fighting against the stethoscope.
Not realising that this tool is being used with the intent to assist, not hinder. For the
unconscious patient or deceased, they have no choice. A nurse just uses the
stethoscope without their willing or knowing.
The stethoscope is an example of a thing that is tangible, visible and physically touchable; it
is a concrete life-world object. However, things do not always present like this. Non-physical,
immaterial moments are ‘non-material things’. Like concrete life-world things, these
moments, too, have properties. However these properties are not touchable; instead, these
properties are often related to the meaningfulness of a moment or situation in which someone
finds themselves, such as being in a hotel room (Van Lennep, 1987), sharing a secret
(Langeveld, 1944) or being at home sick (Van Den Berg, 1972).
3.2.2 On a Background of the World
The life-world extends beyond the physical space to the spaces in reference to the world
within which one lives (Heidegger, 1953/2010). The life-world does not refer to a person’s
nearest surroundings, such as the domestic surroundings of the home or workplace. Things
are experienced in the world. Things only make sense when they are considered within a
certain aspect in the world, against a background of totality or completeness, which
Heidegger called the background (Heidegger, 1953/2010). For example, a stethoscope ‘makes
sense’ if it is used by a nurse with a patient, a veterinarian with an animal or in situations such
as children playing ‘doctors and nurses’.

32
3.2.3 Epoché
Phenomenology is concerned with the relationship between subjects and objects, or people
and things, within the lived-world (Husserl, 1954/1970). Husserl (1900/2001) suggested that
it is possible to remove the minds’ content or abstain from judgement regarding a thing for the
purpose of determining its true nature. This is called ‘bracketing’. When bracketing, an
individual suspends, as much as possible, all opinion, beliefs and presuppositions concerning
the thing in question. This is done to allow things to show themselves as they are in
themselves. Husserl (1900/2001) suggested that it is possible for an individual to remove the
awareness of what a stethoscope is and then when uncovering an experience of using a
stethoscope, finding out what it is like as if it is the first time the thing has been experienced.
Importantly, when exploring an experience, bracketing does not aim to ‘forget’ a thing, such
as what an experience of a stethoscope is for a nurse, or what it may be like being a nurse in
an out-of-hospital environment following a disaster. Instead, bracketing aims to bring into
light the essence of a thing, an ability to describe the thing as it is in itself.
In contrast, Heidegger (1953/2010) argued that it is not possible to bracket things. Bracketing
in a true sense is difficult to achieve, particularly if an experience or thing is something with
which you have been actively engaged for some time or is a moment, such as an experience of
being a nurse in an out-of-hospital environment following a disaster. In fact, Heidegger
(1953/2010) stated that the world is more than just subjects contemplating things. Rather, the
idea of having subjects and things separate from one another is preposterous, as a broader
world exists. Therefore, the exploration of experience should start with the world itself. The
existence of an external world does not need proof; it just needs to be taken as if it exists and
exploration is not required to know this (Heidegger, 1989/2012).

33
Heidegger (1953/2010) maintained that in fact, being in the world is being an active
participant in the world, interacting and responding to the world. It is not as if an individual is
suspended in the world and can only observe it through a pane of glass. Sartre (1943/2003)
suggested moving away from the notion of subjects and objects to use the notions of I and
world, as it would be impossible to imagine a lived-world without I. This lived-world can be
accessed from an experience of the first person’s conscious awareness.
3.3 Conscious Awareness
Things have properties and these things make sense when viewed against a particular aspect
of the subject’s mental content, on a backdrop of the world. As such, an individual’s
intentionality has a number of assumptions, beliefs or presuppositions, and ideas and thoughts
about that thing.
3.3.1 Intentionality.
It is suggested that conscious awareness, or at least the content of the mind, is always directed
towards something (Husserl, 1931/2012; Husserl, 1954/1970). This is the base premise of
phenomenology, in which subjects contemplate things. Husserl used this notion as a
foundational building block to develop his understanding of the world. He gave this the term
intentionality, meaning the ‘directedness’ or ‘towardness’ towards something (Husserl,
1931/2012). This intentionality is about neither the intention of the subject nor the intention of
the thing. Instead, it is a term coined to define the mental consciousness of thought towards a
thing. Following Husserl’s (1900/2001) philosophical stance, if a nurse was using the
stethoscope to hear a patient’s heartbeat, their intentionality is directed towards the
stethoscope when undertaking an activity, such as auscultating.

34
In contrast, Heidegger’s (1953/2010) philosophical stance suggested that a nurse is not
directing their mental content towards the stethoscope or even the heartbeat. A nurse does not
necessarily think about auscultating a patient’s chest; a nurse just does it. A nurse may hold
the stethoscope in one hand against the patient’s chest, listening intently, because they have
been taught to do it this way or they have taught themselves to do it. While undertaking the
activity of auscultating, a nurse may have been able to think about other patients and their
needs, think about the priorities of care for other patients, recall previous conversations or
actions, or observe the patient’s domineer or skin colour. That is, the nurse would not have
been directing all of their mental content towards their stethoscope or the activity of
auscultating. Therefore, the activity of auscultating is not necessarily in the conscious
awareness of a nurse. A nurse may observe the thing to be a stethoscope because the thing
looks like a stethoscope, but when using it on a day-to-day basis, a nurse may not necessarily
have a memory of using it in every occasion on every day, as their actions have passed
through their transparent consciousness (Heidegger, 1953/2000). Instead, what a nurse knows
is that on the completion of their shift, or when the patient is discharged home, a nurse must
have used a stethoscope.
When something goes wrong in the activity of auscultating, such as the nurse no longer
hearing the heartbeat of a conscious patient, then the nurse becomes consciously aware of the
activity of auscultating. It may be that the stethoscope does not have appropriate contact with
the patient’s skin, or that the tubing is kinked, impeding the movement of sound, or that the
bell is open rather than the diaphragm. It is then that a nurse becomes consciously aware of
this activity and directs their mental content to the activity of auscultating with a stethoscope.
For a nurse who experiences an activity such as auscultating every day, it is a somewhat
unconscious activity until an alteration, interruption or problem is encountered. Then the
subject becomes consciously aware of the thing within this activity (Heidegger, 1953/2000).

35
3.4 First Person
3.4.1 Being.
The term being is widely used throughout phenomenology. This term has German origins
from the words da meaning here, and sein meaning being. The word dasein means being here
or existence (Olafson, 1994). Dasein refers to the existence of a human being in the world,
behaving or interacting with the world in a certain manner, rather than in reference to a human
being as a subject (Heidegger, 1953/2000; Heidegger, 1953/2010). Dasein itself at times
could be described as a way of existing for a human being. As such, dasein can be described
as the activity of being in the world, or being within a particular moment, situation or event.
This is an important notion, as this study is exploring the beingness of being an Australian
civilian hospital nurse as part of a disaster medical assistance team in the out-of-hospital
disaster environment following a disaster.
Dasein has the basic characteristics of what Heidegger calls disposition (Heidegger,
1989/2012). For example, mood is a disposition of dasein. It is important to note that a human
being in the world exists in a particular mood. However, this mood does not necessarily arise
from having no mood at all. Instead, things matter to dasein and these things that matter are of
importance. This importance can influence mood. Additionally, dasein is a rationale of being
and is a coping with regard to being (Olafson, 1994). That is, individuals do what they do to
be understood and acknowledged within the world in which they exist. For example, if a
nurse uses a stethoscope to auscultate a patient’s chest to hear a heartbeat, but instead cannot
hear a heartbeat, the nurse has the ability to cope. That is, the nurse will identify the problem
and set out to fix this problem, which may be originating from the stethoscope. As such, a
nurse may twist the end of the stethoscope to open the diaphragm instead of the bell, take and
use another stethoscope, or seek assistance from a colleague. These options may provide a

36
way to achieve the desired outcome of auscultating. The nurse is now consciously aware of
the stethoscope.
3.4.2 Perception.
In phenomenology, the notion of the purpose of the body was not at the fore until Merleau-
Ponty (1945/2002) focused on the way the body interacts with the world, or the way the body
is embodied within the world, to make meaning of the world. This is termed ‘corporality’ and
refers to the lived-body within the lived-world. The notions of corporality or lived-body are
existential notions of the position of body in the lived-world through which the phenomena is
lived through as we actually live through it (Merleau-Ponty, 1945/2002).
The world is perceived through the relationship one has with the world. This is particularly
true in terms of the proximity of the subject to the world. This proximity could be considered
as the relationship of a person or subject to a thing. A person can only experience something
from where they stand. In particular, an individual experiences a thing from the angle or view
from where they stand (Merleau-Ponty, 1945/2002). For example, the closer a nurse is to the
patient, the more detail they can see of the patient. If a nurse holds a patient’s hand, looking
directly at the patients’ hand, the nurse would see the patient’s hand in exquisite detail, noting
all the perfection and imperfection of the hand. When looking at the hand itself, it does not
mean that the nurse is disregarding that a patient exists holistically; it is simply that the patient
as a whole is not at the fore; the hand is.
When a nurse moves back from the hand, an arm can be seen and further back from the arm, a
person or patient can be seen. If a nurse moves further away from the patients’ bedside and
further down the ward, the nurse can not only see the patient, but now a patient in a ward.
This may have meaning for dasein, as a ward has particular characteristics. For example, a

37
nurse could tell if the patient was in an ED, intensive care unit (ICU), general surgical ward or
aged-care facility. At this position on the ward, the nurse can no longer see the intricate
details of the single patient’s hand. Instead, the nurse has an overview of many patients.
At various points in time throughout a shift, nurses position themselves to have an optimal
view of the thing that they wish to experience. At times, this may be a hand of the patient and
at other times, it might be an overview of a number of patients on a ward. Regardless of
where a nurse stands, a nurse will never be in a position to see multiple patients in their
totality and in exquisite detail at the same time, as a nurse cannot see all sides of all patients at
once. The body of dasein is important in understanding an experience, as the body is drawn to
a position in which the perception of dasein is best viewed with an optimal position of the
lived-world (Merleau-Ponty, 1945/2002).
A person cannot experience a thing from where another person stands. Seemingly, the same
situation may not be experienced exactly the same way by individuals because the
individuals’ views, opinions and beliefs differ. Individuals do not perceive and experience the
world in the same way. If this was not the case and all individuals experienced the world in
the same way, the world would be harmonious, homogeneous and monotonous. For example,
if two nurses stand side-by-side at the end of a patient’s bed, looking at the patient, their
perceptions of the patient are not the same. Further, if these two nurses stand face-to-face
conversing about a patient, they do not experience the same thing. Each nurse is able to see
beyond the other nurse to the background, but each nurse cannot experience their own
background. The background may be important. If the patient is in the background of one of
the nurses, this nurse may discuss the patient in a different manner when compared to the
nurse that does not see the patient. The nurse that sees the patient in the background while
conversing about the patient may include the patients’ current condition in the conversation,

Australian civilian hospital nurses’ lived experience of an out-of-hospital environment following a disaster

Australian civilian hospital nurses’ lived experience of an out-of-hospital environment following a disaster

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